Search

Background: We report functional outcomes at six years in patients with varying degrees of fatty infiltration and atrophy of the rotator cuff muscles who have undergone anatomic total shoulder replacement., Methods: A retrospective analysis of case notes and magnetic resonance imaging scans of patients undergoing total shoulder replacement for primary glenohumeral arthritis was performed. Patients were grouped based upon their pre-operative magnetic resonance imaging findings for fatty infiltration, muscle area and tendinopathy. Post-operative functional outcomes were assessed using the Oxford Shoulder Score and Quick Disabilities of the Arm, Shoulder and Hand score. Post-operative measurements were made for active shoulder movements., Results: Thirty-two patients were reviewed at a mean of 67 months following surgery. All patients demonstrated fatty infiltration on their pre-operative magnetic resonance imaging scan. Muscle atrophy was shown in 22 patients and 12 had tendinopathy. Multiple regression analysis showed no correlation between the Oxford Shoulder Score (p = 0.443), the Quick Disabilities of the Arm, Shoulder and Hand score (p = 0.419), forward flexion (p = 0.170), external rotation (p = 0.755) and any of the pre-operative independent variables., Discussion: The degree of fatty infiltration, muscle atrophy and tendinopathy of the rotator cuff muscle on pre-operative magnetic resonance imaging scanning is not associated with functional outcome score or functional movement at medium-term follow-up following total shoulder replacement., Level of Evidence: IV., (© 2018 The British Elbow & Shoulder Society.)

Thumb carpometacarpal joint (CMCJ) osteoarthritis is a common complaint that produces pain and disability within the hand. This study aims to ascertain whether joint injection with local anaesthetic and steroid is of predicative value in disease progression in thumb carpometacarpal osteoarthritis. Forty-three patients were assessed at an average follow up of 24 months following ultrasound-guided injection. Fourteen patients (32%) progressed to surgery, at a mean interval of 8.6 months (range 4-14 months). There was a statistically significant correlation between those patients who had on-going pain following injection at one week and progression to surgery (p = 0.025) with an odds ratio of 3.14 and positive likelihood ratio of 2.1. Patients with thumb CMCJ osteoarthritis that does not respond favourably to injection at one week are likely to progress to surgery in the first year after the injection. This work offers a useful tool in predicting disease progression and patient counseling.

Pyogenic myositis is uncommon. It normally affects the large muscle groups in the lower limb or trunk and the most common causative organism is Staphylococcus aureus. We present a case of an immunocompetent man who, unusually, had a recurring form of the disease in subscapularis and teres minor. The causative organism was also highly unusual (Fusobacterium).

A number of measurements of patellar height are in clinical use all of which reference from the tibia. The patellotrochlear index (PTI) has been proposed recently as a more accurate reflection of the functional height of the patella and described in normal knees. We compared patellar height measurements in patients with patellofemoral dysplasia. In a retrospective analysis of the MRI scans of 33 knees in 29 patients with patellofemoral dysplasia we assessed the inter- and intraobserver reliability of four patellar height measurements: the recently described PTI, Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD) ratios. We also assessed the correlation between the different measurements in predicting patella alta. Three blinded observers on two separate occasions performed the measurements. There were 21 females and 8 males with a median age of 21 years (range 13-33). Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75 and 0.78, respectively). There was weak correlation between the PTI and the other ratios for patella alta. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539, respectively). We propose the PTI as a more clinically relevant measure than the IS, CD and BP ratios.

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.

Purpose. Ifosfamide is a drug commonly used in the management of sarcomas and other solid tumours. One potential toxicity of its use is renal tubular damage, which can lead to skeletal abnormalities; rickets in children and osteomalacia in adults. We aimed to characterise this rare complication in adults. Patients. Three illustrative patient cases treated in our institution are presented. All were treated for sarcoma, and received varying doses of ifosfamide during their therapy. Methods. We performed a review of the literature on the renal tubular and skeletal complications of ifosfamide in adults. Papers were identified by searches of PubMed using the terms "osteomalacia," "nephrotoxicity," "Fanconi syndrome," "ifosfamide," and "chemotherapy" for articles published between 1970 and 2006. Additional papers were identified from review of references of relevant articles. Results. There are only four case reports of skeletal toxicity secondary to ifosfamide in adults; the majority of data refer to children. Risk factors for development of renal tubular dysfunction and osteodystrophy include platinum chemotherapy, increasing cumulative ifosfamide dose, and reduced nephron mass. The natural history of ifosfamide-induced renal damage is variable, dysfunction may not become apparent until some months after treatment, and may improve or worsen with time. Discussion. Ifosfamide-induced osteomalacia is seldom described in adults. Clinicians should be vigilant for its development, as timely intervention may minimise complications.

Trochlear dysplasia is an important anatomical abnormality in symptomatic patellar instability. Our study assessed the mismatch between the bony and cartilaginous morphology in patients with a dysplastic trochlea compared with a control group. MRI scans of 25 knees in 23 patients with trochlear dysplasia and in 11 patients in a randomly selected control group were reviewed retrospectively in order to assess the morphology of the cartilaginous and bony trochlea. Inter- and intra-observer error was assessed. In the dysplastic group there were 15 women and eight men with a mean age of 20.4 years (14 to 30). The mean bony sulcus angle was 167.9 degrees (141 degrees to 203 degrees), whereas the mean cartilaginous sulcus angle was 186.5 degrees (152 degrees to 214 degrees; p < 0.001). In 74 of 75 axial images (98.7%) the cartilaginous contour was different from the osseous contour on subjective assessment, the cartilage exacerbated the abnormality. Our study shows that the morphology of the cartilaginous trochlea differs markedly from that of the underlying bony trochlea in patients with trochlear dysplasia. MRI is necessary in order to demonstrate the pathology and to facilitate surgical planning.

Following arthroscopic anterior cruciate ligament reconstruction, radio-opacities were noted on the post-operative radiographs in 40 of 50 consecutive cases. There was no correlation between the presence of these opacities and post-operative knee pain, joint effusion, arthrofibrosis or knee recovery. In 12 cases undergoing a subsequent radiograph between 3 and 18 months post-operatively, opacities were noted in only one case.

Five cases of penile metastases are presented. Axial and sagittal T1-weighted and T2-weighted scans were performed in all patients. In some, coronal images were also obtained. The penile metastases were most often seen as discrete masses in the corpora cavernosa or corpus spongiosum. An atypical pattern of diffuse infiltration is also illustrated. Limitations of cavernosography, ultrasound (US) and computed tomography (CT) are discussed. The magnetic resonance (MR) features of penile metastases and possible role MR may have in the management of these patients are described.

Patients with suspected malignant spinal cord compression may present with a misleading sensory level or have multiple levels of compression that are not apparent clinically or on imaging of a limited area of the spine. To estimate how often this occurs and to evaluate a policy of magnetic resonance imaging (MRI) of the whole spine for any patient with suspected cord compression, data from 127 patients who had undergone MRI scans of the whole spine were reviewed. In 85 of 127 scans, there was evidence of compression of or impingement upon the spinal cord. A sensory level was present in 47 of these 85 patients, but in 12/47 (26%) the sensory level was four or more segments below or three or more segments above the actual lesion. Multiple levels of compression or impingement were found in 33 of 85 (39%) patients; in 24 of these, more than one region (cervical/thoracic/lumbar) of the cord was involved. For 32 patients who commenced radiotherapy to a treatment volume based on clinical criteria before the MRI scan was available, the radiotherapy fields needed modification in 16 (50%) as a result of the MRI findings. The results support a policy of MRI of the whole spine in any patient with suspected malignant spinal cord compression.

Tibial vessel disease is an important cause of limb ischaemia, particularly in diabetics. Revascularisation by angioplasty and bypass is increasingly feasible. The aim of this study was to review treatment and outcome in patients with this patterns of disease. We have performed 25 procedures in 20 patients since September, 1989. Six patients (5 diabetic) underwent 9 tibial angioplasties for stenotic lesions causing critical ischaemia or short-distance claudication. In 6 procedures there was single vessel run-off. Eight angioplasties were radiologically successful with a median increase in ankle-brachial index (ABI) of 0.15 [range: 0.00-0.44] at a median follow-up of 9 months. A further 4 patients (3 diabetic) with critical ischaemia underwent popliteal-distal, in-situ vein bypass for tibial occlusions. Distal anastomosis was onto the dorsalis pedis artery or distal anterior artery. Three grafts remain patent with successful limb salvage and ABI's greater than 1.0. Angioplasty is also useful for distal disease progression following femoro-popliteal bypass. Six patients with "at-risk" grafts underwent 8 tibial angioplasties for stenotic lesions in distal run-off. Radiologically, 6 procedures were successful with a median increase in ABI of 0.21 [range: 0.00-0.38] at a median follow-up of 7 months. There were less favourable results when a "graft-distal" bypass performed to salvage an occluded femoro-popliteal graft with diseased run-off vessels. Three of 4 grafts reoccluded within 3 months, 2 patients requiring amputation. We advocate an aggressive policy towards localised distal disease causing foot ischaemia.

The radiological and MRI appearances of 24 knees with patellar tendonitis resistant to conservative therapy were analysed to identify the characteristic MRI appearance and to determine if the patellar morphology was abnormal. A significant thickening of the tendon was found in all cases; this was a more reliable diagnostic feature than a high signal within the superior posterior and central aspect of the tendon at its proximal attachment. The site of the lesion shown by MRI is more compatible with impingement of the inferior pole of the patella against the patellar tendon than a stress overload of the tendon. There were no significant differences in the length of the patella, inferior pole or length of the articular surface when the patellar morphology was compared with that of a matched control group.

Objective: The objective of this study was to evaluate the value of magnetic resonance (MR) imaging in the diagnosis of the os trigonum syndrome., Design: Sagittal and coronal spin echo MR sequences of the ankle were acquired along with sagittal images in both dorsiflexion and plantar flexion., Patients: Three consecutive patients presenting with posterior triangle pain were assessed., Results and Conclusions: MR imaging delineated the anatomical site of the abnormality and demonstrated coexisting pathology in all patients. Flexion/extension MR images yielded additional information regarding the mobility of the os trigonum in one patient. MR imaging is the technique of choice for investigating the os trigonum syndrome.

Background: Successful treatment of acute lymphoblastic leukemia (ALL) has resulted in an increasing number of patients whose disease is cured. This treatment includes cranial irradiation as prophylaxis against central nervous system relapse. The late effects of irradiation are well documented, but their incidence is unknown. The authors investigated the late effects of this treatment modality further by scanning 35 long term survivors of ALL who received cranial irradiation., Methods: Thirty-five survivors of ALL with no known complication of treatment were included in this study. They were examined with magnetic resonance imaging (MRI) of the brain and magnetic resonance angiography (MRA) of the circle of Willis. A control group of 24 patients who were cured of other childhood malignancies without exposure to cranial irradiation also were scanned., Results: Fifteen of 35 (43%) abnormalities were found in the study group versus 4/24 (17%) in the control group. Excluding minor atrophic changes that are known to be produced by irradiation and chemotherapy, there were 9/35 (26%) abnormalities in the study group and 1/24 (4%) in the control group (P < 0.05). These abnormalities included three tumors, a meningioma, a paranasal sinus rhabdomyosarcoma, and an anaplastic astrocytoma. In addition, there were two cases of large vessel vasculopathy, two small cystic infarcts, one diffuse white matter abnormality, and one cryptic vascular malformation. The abnormal control patient had a cerebellar infarct., Conclusion: Complications of cranial irradiation in the treatment of ALL appear to be more frequent than currently are appreciated. That these complications include tumors that are potentially treatable suggests that screening may be valuable for these patients.

100 consecutive magnetic resonance imaging (MRI) examinations were reviewed independently by two radiologists. Patients were selected so that the anatomical areas of clinical interest coincided with the special interests of the reviewers. The reviewers were both consultant radiologists, one with 3 years' and the other with 6 years' experience of MRI. Hard copy images from the MRI examinations were reported independently by both reviewers. Of the 100 MRI examinations, there was full concordance of opinion in 61/100. Of the remaining 39 cases, four (10%) were considered "minor unrelated" differences, 12 (31%) "minor related" differences and 23 (59%) "major related" differences resulting in a significant change in patient management.

Objective: Our aim was to evaluate a novel means of assessing ocular motility disorders using MRI., Materials and Methods: A GE image of the orbit was acquired in a set plane each time the patient fixed on a series of points spread across the field of view. The images were transferred in sequence to a video recorder to create a cineloop of ocular movement. The technique was used in 33 patients with a range of ocular motility disorders including thyroid eye disease, posttraumatic diplopia, and Duane syndrome., Results: In addition to anatomical detail, functional information could be derived from motion of the globe, motion of the optic nerve, and contractility of individual muscles. This is of particular use to the ophthalmic surgeon in disorders of ocular motility following eye surgery., Conclusion: A method of recording eye movements using MRI is described that offers useful functional information in the evaluation of disorders of ocular motility.

Objectives: To assess the accuracy of Duplex ultrasound in the assessment of aortoiliac disease., Design: Prospective, semi-blind study., Setting: Vascular laboratory and radiology departments, University Hospital., Materials and Methods: Ninety-two patients underwent assessment of the aortoiliac segment by femoral pulse palpation, Duplex ultrasound and biplanar arteriography. Of these 184 aortoiliac segments, 68 were also assessed by intraarterial pressure measurements and 80 by magnetic resonance angiography (MRA)., Main Results: Femoral pulses were abnormal in all 32 occluded aortoiliac segments. Of 152 patent segments, femoral pulse palpation was misleading in 50 (33%). MRA detected all occlusions and had a sensitivity of 71% and specificity of 68% for stenoses, compared to arteriography. Colour flow Duplex misdiagnosed four occlusions as stenoses. Duplex had a sensitivity of 91% and specificity of 93% for stenoses when compared to arteriography. Two stenoses, detected by Duplex and confirmed by pressure gradients, were missed by arteriography., Conclusions: Pressure measurements remain the gold standard for aortoiliac examination, arteriography providing only morphological information. The limitations of femoral pulse palpation should be appreciated. Although MRA was faster, Duplex examination proved slightly more sensitive to stenoses. At present, colour Duplex provides the best non-invasive assessment of aortoiliac disease and could prevent unnecessary arteriograms.

Pulse-generated run-off (PGR) is an established technique in the assessment of calf vessel patency. Dependent Doppler ultrasonography is proposed as a fast and simple alternative. Twenty-six limbs with severe ischaemia were evaluated by PGR, dependent Doppler examination and intra-arterial digital subtraction angiography (DSA). PGR was performed and scored as previously described. Dependent Doppler ultrasonography was performed after 5 min of foot dependency and scored as for PGR. Angiograms were scored by an independent radiologist, who awarded 2 for a vessel widely patent to the ankle, 1 for a diseased vessel crossing the ankle and 0 if no vessel was visualized. Of 78 calf vessels evaluated, 59 (76 per cent) appeared patent on PGR and dependent Doppler examination but only 33 (42 per cent) appeared patent to the ankle with intra-arterial DSA. There was very good agreement between PGR and dependent Doppler for detection of patent calf vessels (kappa = 0.93). Doppler signals were biphasic in six calf vessels on dependency and in 22 vessels with PGR. PGR and dependent Doppler ultrasonography detected 26 vessels communicating with the pedal arch compared with seven detected angiographically. There was good agreement between PGR and dependent Doppler examination for diagnosis of the most suitable vessel for distal anastomosis (kappa = 0.80). The wide availability and simplicity of dependent Doppler ultrasonography mean that no patient with a critically ischaemic limb should be denied reconstructive surgery on the basis of angiographic findings alone.

Subclavian artery aneurysms are rare. Diagnosis is important as complications can be life threatening. A case is reported which is diagnosed by magnetic resonance imaging; moreover it is suggested that magnetic resonance imaging is now the initial imaging modality of choice in the investigation of these lesions.

Accurate diagnosis of internal carotid artery (ICA) occlusion is essential in the investigation of carotid disease yet may be difficult using Duplex. Traditionally contrast arteriography has been used to confirm the diagnosis despite its cost and potential dangers. Twenty-one patients with 23 ICA occlusions were evaluated by a 3-dimensional time of flight magnetic resonance angiography (MRA) technique. The cervical carotids and circle of Willis were imaged during the MRA examination which lasted 30 minutes. Confirmatory conventional angiography was performed in all patients. Using angiography as the gold standard, all occlusions were correctly diagnosed by MRA and 22 of 23 occlusions correctly diagnosed by Duplex. There was good agreement between MRA and angiography for all 42 ICAs imaged (Kappa statistic 0.83). Diagnosis of internal carotid artery occlusion is critical as it determines the need for operation. In this situation MRA provides a useful non-invasive complement to Duplex. A combination of non-invasive studies may enable arteriography to be rejected with greater confidence in this high risk group.

Fifty patients undergoing 51 percutaneous transluminal angioplasties of the femoropopliteal segment for severe limb ischaemia were reviewed regularly. They comprised 30 men and 20 women of median age 70 (range 56-85) years. There were two deaths within 30 days. At 2 years the cumulative patient survival rate was 60 per cent. Eleven angioplasties were technical failures, 25 failed in the first 6 months and 14 were successful at 6 months' follow-up; in addition one patient died from myocardial infarction within 30 days of technically successful angioplasty. Subsequent vascular procedures were successful in 11 limbs following failed angioplasty. The primary limb survival rate was 42 per cent at 2 years. There were eight major complications after angioplasty, requiring amputation in five instances. Of the 23 long occlusions (greater than 5 cm) that were recanalized and dilated, 22 procedures failed within 6 months. The run-off score and diabetic status did not predict outcome. In this group of patients angioplasty had a low durability. Dilatation of long occlusions is associated with high rates of reocclusion and, on the basis of these results, should not be performed.

It has been stated that chest radiographic features of aortic dissection are a contraindication to intravenous thrombolysis in patients with suspected acute myocardial infarction. Excluding aortic dissection could significantly delay such treatment in patients who would benefit from thrombolysis. Initial chest radiographs of 18 patients with acute aortic dissection and 25 patients with acute myocardial infarction were evaluated. The radiographs were studied by two experienced radiologists for signs of aortic dissection. No radiographic signs or combinations of signs accurately distinguished aortic dissection from myocardial infarction. Patients with chest radiographic signs suggesting aortic dissection but with clinical features suggesting myocardial infarction should not be denied the benefits of immediate intravenous thrombolysis.

The MR images of 34 patients with soft tissue lesions were retrospectively evaluated to assess the accuracy of the technique in distinguishing benign from malignant lesions, and to assess the usefulness of various criteria in making this distinction. The overall sensitivity for the detection of malignancy was 75% with a specificity of 94%. Size of lesion was found to be a good criterion in predicting malignancy, lesion margin and signal intensity were less useful. The tissue type was determined in a few instances where signal characteristics were typical, notably lipomas and neural tumours, but this was not reliable and in most lesions the tissue of origin cannot be determined on MR imaging and biopsy is necessary.

We describe an effective splint for sprains of the metacarpophalangeal joint of the thumb.